Surgical Pathology Cancer Case Summary

EXTRAHEPATIC BILE DUCTS:             Report

EXTRAHEPATIC BILE DUCTS: Resection

MACROSCOPIC (check all that apply)

SPECIMEN TYPE

___ Pancreaticoduodenectomy

___ Segmental resection of bile ducts(s)

___ Choledochal cyst resection

TUMOR SITE

___ Unknown

___ Right hepatic duct

___ Left hepatic duct

___ Junction of right and left hepatic ducts

___ Cystic duct

___ Common bile duct

___ Proximal

___ Middle

___ Distal

MICROSCOPIC (check all that apply)

HISTOLOGIC TYPE

___ Carcinoma in situ

___ Papillary adenocarcinoma

___ Adenocarcinoma, intestinal type

___ Mucinous adenocarcinoma

___ Adenosquamous carcinoma

___ Squamous cell carcinoma

___ Other: __________________

HISTOLOGIC GRADE

___ Not applicable

___ GX: Cannot be assessed

___ G1: Well differentiated

___ G2: Moderately differentiated

___ G3: Poorly differentiated

___ G4: Undifferentiated

EXTENT OF INVASION

___ TX: Cannot be assessed

___ T0: No evidence of primary tumor

___ Tis: Carcinoma in situ

___ T1: Tumor invades subepithelial connective tissue or fibromuscular layer

___ T1a: Tumor invades subepithelial connective tissue

___ T1b: Tumor invades fibromuscular layer

___ T2: Tumor invades perifibromuscular connective tissue

___ T3: Tumor invades adjacent structures: liver, pancreas, duodenum, gallbladder, colon, stomach

MARGINS

___ Uninvolved by tumor

Distance of tumor from closest margin: ___ cm

(specify margin: _________________________)

___ Involved by tumor

___ Proximal bile duct margin

___ Distal bile duct margin

___ Radial margin

___ Other (specify:__________________)

REGIONAL LYMPH NODES

___ NX: Cannot be assessed

___ N0: No regional lymph node metastasis

Number examined: ___

___ N1: Metastasis in cystic duct, pericholedochal and/or hilar lymph nodes (i.e., in the hepatoduodenal ligament)

___ N2: Metastasis in peripancreatic (head only), periduodenal, periportal, celiac, and/or superior mesenteric and/or posterior pancreaticoduodenal lymph nodes

DISTANT METASTASIS

___ MX: Cannot be assessed

___ M0: No distant metastasis

___ M1: Distant metastasis (site(s):____________

________________________________________)

ADDITIONAL PATHOLOGIC FINDINGS

___ None identified

___ Dysplasia

___ Cholangitis

___ Stones

___ Other (specify: ____________________)

COMMENT

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